module 3 - overcoming avoidance - wa health...module 3: overcoming avoidance introduction so far in...

Stepping Out of

Social Anxiety

Stepping Out of Social Anxiety

Module 3

Overcoming Avoidance

Introduction 2

What is Avoidance? 2

Why is Avoidance a Problem? 2

The Vicious Cycle of Anxiety and Avoidance 3

Behavioural Experiments 4

Behavioural Experiment - Example 5

Testing Probability and Cost 6

Behavioural Experiment – Testing Cost Example 7

Conducting Behavioural Experiments 8

My Behavioural Experiment 9

Extra Tips for Behavioural Experiments 10

Module Summary

11

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Module 3: Overcoming Avoidance

Introduction

So far in the modules you have learned about what social anxiety is, what keeps it going, and how to challenge your negative thinking about social situations. In this module we will focus on avoidance and how it keeps us stuck in our anxiety. We will learn why it is important to approach the situations that make us anxious rather than avoiding them. This might sound hard, but we will also look at how we can break things down to do this step by step.

What is avoidance? Avoidance behaviours are things we do to escape upsetting feelings. As outlined in Module 2, our thoughts about social situations influence how we feel and what we do. If we think that a social situation will not go well, we will probably feel anxious about it. If you feel anxious, or anticipate feeling anxious, it makes sense that you will do things to reduce your anxiety. Sometimes, people will try to reduce their anxiety by avoiding the feared situation altogether. This usually results in instant relief and reduction of anxiety, as we no longer have to face the feared situation. Some typical situations that people with social anxiety avoid include:

• unfamiliar people • large groups of people • attending appointments • phone calls • answering emails • public places • certain kinds of people (e.g. those our own age, older people, people in a position of

authority, people we are attracted to)

Why is avoidance a problem? Although in the short-term avoidance may help us to feel safer and less anxious, in the longer-term avoidance keeps us anxious for a number of reasons. 1. We never get to test our negative thoughts. When we avoid a social situation we are assuming that our negative thoughts are accurate. However, avoidance never gives us an opportunity to directly test our fears. If we did, we might discover that our thoughts are actually inaccurate. We might learn that our fears rarely occur and instead that things often turn out better than expected. We might also find that even if social experiences don’t go to plan sometimes, then we can cope with this as well. So avoidance prevents us from getting an accurate impression of the true probability and cost of our fears coming true. 2. We never get opportunities for positive experiences. As long as we avoid social situations, we have no chance of having positive social experiences that would motivate us to engage more socially over time. 3. Loss of self-esteem. Because people with social anxiety aren’t doing what they would really like to do (e.g. have more satisfying relationships) they tend to be very self-critical and can have low self-esteem. They may ruminate about aspects of life that are passing them by, which leaves them more vulnerable to further anxiety and depressed mood. In fact, people with social anxiety can often use their avoidance as just another reason to criticise themselves. 4. Avoidance and anxiety can spread. As we avoid situations and lose confidence in an area of our lives (e.g., relationships with peers), our anxiety can start to spread out to more and more areas of our life (e.g., relationships with people at work, family relationships).



The vicious cycle of anxiety and avoidance

The vicious cycle of anxiety is illustrated below:

It is crucial that the cycle of avoidance and increasing anxiety is broken. To start breaking this vicious cycle, it is important to start approaching the situations that make us feel anxious. In the short-term this might increase our anxiety, but it gives us the opportunity to test our fears and build confidence in our own coping skills, which helps to reduce our anxiety over time. This is shown in the cycle of progress below.

Negative expectations are strengthened

Anxiety

Avoidance

Long term Never test negative expectations Miss out on positive experiences

More self-criticism Start feeling anxious in more situations

Short term Relief

More realistic expectations

Anxiety reduces

Start by approaching

situations

Long term Opportunity to test negative expectations

Opportunity for positive experiences Less self-criticism

Build confidence in own ability to cope

Short term Feel more anxious



Tip: Using imagery can help you identify your predictions about a social situation. Try closing your eyes and imagining yourself in that situation, as vividly as you can, as if you were experiencing it right now. What are you seeing happen? What are you doing? What are other people doing? How are they responding to you?

Behavioural Experiments Just like a scientist who uses an experiment to test a prediction, behavioural experiments are designed to test our negative predictions about social situations. Behavioural experiments provide a structured way of systematically and directly testing our fears. Sometimes, just ‘taking the plunge’ and rushing in to situations that make us anxious might not help us test our fears properly. We might spend the whole time we are in the social situation focused on just getting through it, or selectively focusing on negative details, and might not notice the information we need to test our fears. Approaching feared situations in a structured way by using behavioural experiments can help us make sure we focus on the information we need to test our fears.

Conducting a behavioural experiment involves taking a step back from our negative thoughts. Rather than assume our negative thoughts are definitely accurate, we will treat them as ‘just a prediction’ and test them out. The goal of behavioural experiments is to find out what really happens in social situations, so that we can learn to think in realistic ways. There are a number of steps to conducting a behavioural experiment that enable us to learn as much as possible from social experiences:

1. Negative thoughts: Identify a social situation that triggers anxiety for you and write down what you think will happen in the social situation.

2. Rate your anxiety (?/10): Rate the intensity of your anxiety about this situation (0 = no anxiety, 10 =

extreme anxiety) 3. Plan an experiment: Plan your experiment. What could you do to find out how accurate these

thoughts are? How could you find or create a situation that would enable you to test the accuracy of these thoughts?

4. Evidence to observe: What evidence would you need to look for to check the accuracy of your

thoughts? An important note is that this evidence must be clear, observable, and objective evidence. One way of thinking about evidence is to consider whether the evidence would hold up in a court of law, or would the judge disregard it because it was too subjective or just an opinion instead of a fact.

5. Conduct the experiment: Do the experiment 6. Results: Note the results of your experiment. What evidence did you observe? 7. Develop conclusions: What does the evidence tell you about your initial negative thoughts?

Our brains are prone to falling back into old thinking habits. If we learn something from the experiment that is different to what we expect, it is helpful to reinforce this new learning. This can make it easier to bring to mind new and helpful information when you need it in the future. Some ways to reinforce new information include: • Visualising any helpful conclusions you have come to. • Repeating helpful conclusions in your mind. • Jotting down any helpful conclusions on a post-it note or in your phone. • Re-reading your behavioural experiment records. On the next page you will find an example of how to record a behavioural experiment.



Behavioural experiment example - Charlotte Charlotte is anxious when buying her groceries. She tends to avoid it and to shop online whenever possible. She worries that when she speaks to the cashier her mind will go blank or she will say something stupid. She also worries that the people in line behind her will make negative judgements about her purchases, and that they will think she is lazy for buying microwave meals. Her anxiety about doing grocery shopping is 8/10. Charlotte completed the following experiment to test her fears. Negative Thoughts

Describe your prediction. Specifically, what do you think

will happen? What negative images do you

have about the situation?

Anxiety /10

How anxious do you feel?

Experiment Specifically, what could you do to test these thoughts?

Evidence to Observe

Specifically, what do you need to look for to confirm or disconfirm your thoughts?

Results What happened? What clear

evidence did you collect? Stick to unambiguous facts.

Conclusion What conclusion follows from your results?

How can you keep this new information in mind? How can you find more opportunities to test

your predictions?

The cashier will ask me a basic question and I won’t be able to answer. I will freeze up at first, and

then blurt out something stupid. The cashier will

think I am weird.

People lined up behind me will judge me for what I buy. They will think I am lazy for buying microwave

meals.

8/10

Buy groceries at the

shops, including some microwave meals.

Talk to the cashier.

Can I respond to the

cashier without freezing? Are there any objective

signs the cashier thinks I am weird (e.g. making a

comment about me being weird)?

Do people behind me pay attention to what I

buy? Do they say anything to me or make comments to each other

about me being lazy?

The cashier asked about

my day. I was able to answer without freezing. I couldn’t see any sign that she thought I was

weird.

No one behind me seemed to pay much

attention to my purchases. They seemed to be focused on what

they were doing. Nobody said anything about me

being lazy.

My predictions were not accurate this

time.

I was able to talk without freezing, even though I was anxious.

People did not seem to be overly

focused on me.

I was expecting the worst and it didn’t happen.

I am going to put a reminder note on my grocery bag, so I remember this

next time I go shopping.

I’m going to try this experiment out again the next time I go shopping.



Testing probability and cost

As described in Module 2, when people with social anxiety anticipate what is going to happen in a social situation, they tend to overestimate threat in two ways. Firstly, they tend to overestimate the probability or likelihood of their social fears coming true. Secondly, they tend to overestimate the ‘cost’ or how bad it would be if their social fears did come true. Behavioural experiments can be designed to test the probability or the cost of a social fear coming true. In the example above, Charlotte tested the probability of her social fears, as she was testing how likely it was that she would freeze or say something stupid when speaking to the cashier. She found that this was less likely than she initially expected. However, even if we learn that our social fears are very unlikely to come true, if we still think the cost would be bad then we may still feel anxious. If we think there is even a 1% chance of a social catastrophe, we will still feel anxious. It is therefore very important to test the cost of our social fears. People with social anxiety often have a very narrow range of what they think other people will accept and what they can cope with. They feel like they are ‘walking a tightrope’ of what is socially acceptable, and if they put a foot wrong it will be a disaster. This puts them under a lot of stress and pressure when they are socialising. It is important to test whether the costs of making mistakes or doing something socially unusual are as bad as we expect. By testing the cost of our fears we may learn that there is more leeway than we expect in social situations – we may find out that we can put a foot wrong at times, and that nothing bad will happen. Learning this can really ease the pressure and stress in social situations. On the next page you will find an example of a behavioural experiment Charlotte designed to test the cost of her social fears coming true.



Behavioural experiment – testing cost example - Charlotte Charlotte is anxious when buying her groceries. She worries that when she speaks to the cashier her mind will go blank or she will say something stupid. Last time she went shopping, she tested this fear by speaking to the cashier. She learned that the conversation went okay, and that she did not freeze or say anything stupid. This made her feel a bit less anxious, and her anxiety about doing grocery shopping is now 7/10. However, she is still worried that if she did freeze or say something stupid, the cashier would think she was weird and would laugh at her. She is still nervous this could happen one day, even if it is less likely than she first expected. Charlotte completed the following experiment to test her fears.

Negative Thoughts Describe your prediction.

Specifically, what do you think will happen?

What negative images do you have about the situation?

Anxiety /10

How anxious do you feel?

Experiment Specifically, what could you do to test these thoughts?

Evidence to Observe

Specifically, what do you need to look for to confirm or disconfirm your thoughts?



Conclusion What conclusion follows from your results?

How can you keep this new information in mind? How can you find more opportunities to test

your predictions?

If I freeze up or say something stupid the cashier will think I am weird. She will laugh at me, and will make fun

of me to the other customers.

7/10 Talk to the cashier when I am buying

groceries. Deliberately freeze and then say something stupid on purpose to see how

she reacts.

Are there any objective signs the cashier thinks I am weird (e.g. making a comment about me

being weird)?

Does the cashier laugh at me in a negative

way? (I will know she is laughing at me if it

happens directly after I speak, whilst she is looking at me. I will know it is negative

based on her tone and facial expression).

Does the cashier make fun of me to the other customers (e.g., do I

hear them talking about me negatively)?

The cashier asked about my day. I froze on purpose for a few seconds. She didn’t seem

to react to that and just waited for me to say

something.

I said “I am having a good weekend so far” even though it is Wednesday. The cashier laughed a little bit, but she was smiling at me. She said

“I’m thinking about the weekend too! It can’t come soon enough”. Then she just

kept talking about other things.

When I had finished paying, the cashier just moved on and asked the next person

how their day was. She didn’t make any comments

about me.

The cashier didn’t seem to care when I froze.

When I said something that was

wrong, she laughed but acted friendly instead of mean. She kept the

conversation going and didn’t seem focused on me saying something

stupid. She didn’t make fun of me.

Maybe it is not such a big deal to make a mistake or say something

stupid.

People act more nicely than I expect them to.

I am going to replay this in my mind a few times to help me remember what

happened.



Conducting experiments Now it is time to put things into action and start to conduct behavioural experiments. Choose a social situation that you would be willing to approach, even though you feel anxious about it. You might choose to start with an experiment that only generates mild anxiety, and work your way up to more challenging behavioural experiments – see module 4 for more details on this. Use the blank behavioural experiment record on the next page to plan a behavioural experiment that will help you test your fears. Fill in the first four columns on the Behavioural Experiment Record to plan your behavioural experiment, and then conduct the experiment to gather your results. After you finish conducting the experiment, complete the final two columns on the Behavioural Experiment Record worksheet to record what you observed and what you learned from the experiment. It is important to keep conducting behavioural experiments regularly. Research shows that regularly conducting behavioural experiments is more effective than doing them ‘now and then’. Doing several behavioural experiments every week is the most helpful approach. This might mean repeating the same experiment several times, or it might mean taking a new step by approaching a more challenging situation. Keep using the Behavioural Experiment record on page 9 to plan behavioural experiments and record what you learn.



Behavioural experiment record Negative Thoughts

Describe your prediction. What goes through your mind? What do you see happening?

What negative images do you have about the situation?

Anxiety How anxious do you feel (0-10)?

Experiment Specifically, what could you do

to test your predictions?

Evidence to Observe Specifically, what do you need to

look for to confirm or disconfirm your predictions?



Conclusion What conclusion follows from your results? How can you keep this new information in

mind? How can you find more opportunities to test

your predictions?

Fill in these columns BEFORE the experiment Fill in these columns AFTER the experiment



Extra tips for behavioural experiments

Remember, anxiety can influence what we pay attention to, how we interpret things, and how we remember things. When we are anxious we tend to pay the most attention to negative aspects of a situation. This can involve negative aspects of our own experience (e.g. noticing how uncomfortable we feel), or threatening aspects of the situation (e.g. searching people’s faces for any signs of boredom). When we are anxious, we also tend to interpret ambiguous things in a negative way (e.g., if someone yawns we might take that as proof we are boring, but there are many other reasons someone might yawn). This means we might not pay attention to neutral and positive aspects of a situation, and we might misinterpret things in an overly negative way. As we can only remember the information we paid attention to in the first place, these unhelpful automatic tendencies can leave us with a negative memory of a situation, although this might not be an accurate reflection of what really happened. In order to get the most accurate information you can, it is important to…

1. Plan what you need to pay attention to during the experiment to test your fears. This helps you know what evidence you need to pay attention to in order to test your thoughts, rather than just automatically focusing on the negative aspects of the situation. For example, imagine you are trying to test the fear “when I walk down the street, everyone will stare at me”. If you walked down the street with your eyes looking down at the ground then you are not going to gather any information about whether other people were staring or not. In order to find out whether other people are staring or not, you would need to pay attention to looking at other people as you walked down the street.

2. Write down the evidence you collect, and make sure it is objective, factual evidence (rather than opinions or assumptions). This can help make sure you are not being overly negative in the way you interpret things. For example, if you have a prediction “other people will laugh at me”, whenever you hear laughter you might quickly assume that people are laughing at you. However, there are many other explanations for why people might be laughing (e.g. they may be laughing at something someone else said, or something they are reading). You would need to collect more evidence to know whether the laughter was about you or about something else (e.g. observe whether they are looking at you or looking elsewhere while laughing).

3. Write down the conclusions of the experiment. This helps you remember things as they really happened, rather than your anxiety leaving you with a memory focused on the negative aspects of a situation.



Module Summary

• Avoidance keeps social anxiety going, because it stops you from testing your fears and erodes your confidence in your coping

• To break the vicious cycle of avoidance and anxiety it is important to approach the situations that

make you feel anxious. This might increase anxiety in the short-term, but in the longer-term will help you overcome social anxiety.

• Behavioural experiments can be used to test your fears in a structured way. When you conduct behavioural experiments, there are several points that are helpful to remember.

Writing down the experiment is important, as it helps to counteract biases in our attention and

memory.

It is important to conduct behavioural experiments regularly – research shows consistent practice will have the best impact.

It is important to test both the probability and the cost (or consequences) of our fears.

Learning that our fears are less likely to come true than we expected will help reduce our anxiety. However, if we continue to believe that there would be very severe consequences of our fears coming true, some anxiety will remain. You can use behavioural experiments to test the probability or the cost of your social fears.

Coming Up… In the next module we will introduce ‘stepladders’ as a tool to help you plan a step by step way to approach situations you are anxious about. Taking things step-by-step can make it easier to get started, and can help you build confidence as you go.



About the Modules

CONTRIBUTORS Samantha Bank (MPsych1) Melissa Burgess (MPsych1) Clinical Psychologist Clinical Psychologist Dr Adelln Sng (MPsych1; PhD2) Dr Mark Summers (MPsych1; PhD2) Senior Clinical Psychologist Senior Clinical Psychologist Dr Bruce Campbell (MPsych1; DPsych3) Dr Peter McEvoy (MPsych1; PhD2) Consultant Clinical Psychologist Senior Clinical Psychologist Professor, School of Psychology, Curtin University 1Masters of Psychology (Clinical Psychology) 2Doctor of Philosophy 3Doctor of Psychology (Clinical)

Some of the materials in the modules of this information package were taken from:

McEvoy, P. & Saulsman, L. (2017). Imagery-Based Cognitive Behaviour Group Therapy for Social Anxiety Disorder (IB-CBGT). Perth, Western Australia: Centre for Clinical Interventions.

BACKGROUND The concepts and strategies in the modules have been developed from evidence based psychological practice, primarily Cognitive Behaviour Therapy (CBT). Examples of this are reported in: McEvoy, P. M., Hyett, M. P., Bank, S. R., Erceg-Hurn, D. M., Johnson, A. R., Kyron, M. J., Saulsman, L. M., Moulds, M. L., Grisham, J. R., Holmes, E. A., Moscovitch, D. A., Lipp, O. V. Campbell, B. N. C., & Rapee, R. M. (in press). Imagery-enhanced versus verbally-based group cognitive behavior therapy for social anxiety disorder: a randomized clinical trial. Psychological Medicine. http://dx.doi.org/10.1017/S0033291720003001

Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–327.

REFERENCES These are some of the professional references used to create the modules in this information package.

McEvoy, P. M., Saulsman, L. M., & Rapee, R. M. (2018). Imagery-enhanced CBT for social anxiety disorder. Guilford Press.

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (Eds., 2011). Oxford Guide to Imagery in Cognitive Therapy. Oxford:Oxford University Press.

Kemp, N., Thompson, A., Gaston, J., & Rapee, R. (2003). Cognitive behavioural therapy-enhanced for social anxiety disorder: group treatment program. Centre for Emotional Health, Macquarie University.

Saulsman, L. M., Ji, J. L., & McEvoy, P. M. (2019). The essential role of mental imagery in cognitive behaviour therapy: what is old is new again. Invited review for Australian Psychologist, 54, 237-244. doi: 10.1111/ap.12406.

“STEPPING OUT OF SOCIAL ANXIETY” This module forms part of:

Bank, S., Burgess, M., Sng, A., Summers, M., Campbell, B., & McEvoy, P. (2020). Stepping Out of Social Anxiety. Perth, Western Australia: Centre for Clinical Interventions.

ISBN: 978 0 9757995 1 2 Created: October, 2020

https://urldefense.com/v3/__http:/dx.doi.org/10.1017/S0033291720003001__;!!Lav448XFWxY!trMbHPL41bFfTkRTu1_WteekGMF-1eX52ERJismudEVwvqtdS_qGQeHMfvfNQnO8yRGkIcs$

Module 3What is avoidance?Why is avoidance a problem?The vicious cycle of anxiety and avoidanceBehavioural ExperimentsAbout the ModulesContributorsBACKGROUNDRapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Testing the efficacy of theoretically derived improvements in the treatment of social phobia. Journal of Consulting and Clinical Psychology, 77, 317–327.REFERENCES“Stepping out of social anxiety”

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